乳腺癌内乳前哨淋巴结活检的研究现状

区域淋巴结转移是乳腺癌最重要的预后指标。大量资料表明同时伴有腋淋巴结和内乳淋巴结转移的乳腺癌患者预后较差，以往随机临床试验证实内乳淋巴结清扫并不能提高患者的生存率；而该区的放疗因对心脏的潜在毒性而存在广泛争议。然而近十年来，前哨淋巴结活检的应用重新唤起了人们对内乳淋巴结转移的研究兴趣。乳腺癌内乳前哨淋巴结活检在完善分期的基础上，指导辅助治疗，并且在辅助放疗的靶区选择上达到了充分的共识。本文阐述了内乳淋巴结转移及其在乳腺癌中的预后、分期和治疗中的作用，以及内乳前哨淋巴结研究的最新进展。     

淋巴闪烁显像与乳腺癌前哨淋巴结活检

乳腺癌前哨淋巴结的精确定位是乳腺癌前哨淋巴结活检成功的先决条件之一,明确乳腺淋巴引流途径对乳腺癌前哨淋巴结的准确定位有重要指导意义。术前淋巴闪烁显像可提供个体化的淋巴引流特点,有助于确定前哨淋巴结的位置、数目及是否存在腋窝外前哨淋巴结。现对淋巴闪烁显像在乳腺癌前哨淋巴结活检中的应用现状和存在的问题进行综述。     

乳腺癌内乳区前哨淋巴结活检术研究进展

内乳区淋巴结的转移状况是乳腺癌的独立预后指标,也：是乳腺癌淋巴分期的重要依据之一。内乳区淋巴结转移的患者预后较差。随着前哨淋巴结活检技术的不断发展和新型注射技术的出现,内乳区前哨淋巴结活检的显像率显著提高,经肋间行内乳区前哨淋巴结活检术可以最小的风险评估内乳区淋巴结状况,并进一步完善乳腺癌的淋巴结分期．有助于为患者制定更为准确的个体化治疗方案。     

经肋间隙探查定位于内乳区的前哨淋巴结对乳腺癌淋巴分期的影响

目的 探讨乳腺癌前哨淋巴结在内乳区时对其探查与否对淋巴结分期的影响。方法 2006-01—2016-01间,对501例c T1-4N0-1M0期乳腺癌患者进行前哨淋巴结探查术,发现有蓝染淋巴管通向内乳区的患者,经肋间隙入路行内乳区前哨淋巴结活检术(IM-SLNB)+腋窝前哨淋巴结探查+改良根治术100例为A组;行腋窝前哨淋巴结探查+改良根治术401例为B组。观察A组经肋间隙入路IM-SLNB的病理结果与假设该组病例不探查相对比,了解探查对其淋巴分期的影响。观察经肋间隙入路的IMSLNB对手术时间、出血、并发症及恢复等的影响。结果 A组探查发现内乳区淋巴结癌转移19例相对于假设不探查为0例,其淋巴结分期修正率19.0%,(P0.05)有统计学意义;经肋间隙入路IM-SLNB阶段所用时间(23.93±5.89)min;仅1例术中胸廓内动脉出血,切断肋软骨显露血管后结扎止血,出血量约10~20 m L,其余99例均5 m L;胸膜破损0例、气胸0例;术后并发症和愈合时间与B组无统计学差异(P0.05)。结论 选择乳腺癌前哨淋巴结在内乳区时对其进行探查其阳性率高,有助于淋巴结准确分期;经肋间隙入路的内乳区淋巴结探查,创伤小、风险小、不增加并发症。     

前哨淋巴结活检和乳腺癌

前哨淋巴结活检目前正成为乳腺癌外科治疗的研究热点，本文将对其最新的发展进行综述。     

经肋间隙取内乳区前哨淋巴结活检术的临床意义(附51例报告)

目的探讨内乳区前哨淋巴结活检的方法及意义。方法于2003年6月至2004年11月,选择内乳区淋巴结显像的51例乳腺癌病人并确定内乳前哨淋巴结,术中再次用γ探测仪、蓝色染料确认前哨淋巴结的位置,切开肋间肌,经肋间隙胸膜外切除内乳区前哨淋巴结及其他内乳淋巴结。结果51例病人检出内乳前哨淋巴结共54枚,手术时间(31±7)min。检出1枚前哨淋巴结48例,2枚3例,其中发生癌转移18例,共19枚。前哨淋巴结位于第2、3肋间隙者分别为13枚和20枚。用3种方法联合定位内乳前哨淋巴结,其敏感性和特异性均为100%,总准确率为100%。51例共检出内乳淋巴结118枚,其中发生癌转移25枚。无前哨淋巴结转移者未见内乳区其他淋巴结转移。无并发症发生。结论经肋间隙取内乳区前哨淋巴结活检为明确内乳淋巴结转移状况提供了有效的方法。     

保乳术+前哨淋巴结活检治疗早期乳腺癌的效果和安全性研究

目的 探讨保乳术+前哨淋巴结活检(SLND)治疗早期乳腺癌的临床效果和安全性.方法 回顾性分析2018-01—2020-06确山县人民医院普外科行手术治疗的80例早期乳腺癌患者的临床资料.按手术方法分为保乳术+SLND组与改良根治组.比较2组患者的基线资料、围术期指标,以及术后6个月时患侧上肢功能量表(ROM)评分和生...     

术前淋巴显像在乳腺癌前哨淋巴结活检术中的价值

目的 探讨术前淋巴显像在乳腺癌前哨淋巴结活检术（SLNB）中的价值。方法 前期回顾性分析山东省肿瘤医院2000年9月至2007年6月接受SLNB的716例乳腺癌病人的资料,所有病人均行术前淋巴显像;后期的前瞻性研究共入组山东省肿瘤医院2007年7月至2009年11月接受SLNB的565例乳腺癌病人,随机分为术前淋巴显像组和不行淋巴显像组。结果 回顾性研究术前淋巴显像成功率为86.6%,只与术后腋淋巴结病理状况显著相关（P=0.003）;术前腋窝淋巴显像成功与失败组间核素法SLNB成功率的差异有统计学意义（P<0.001）,但核素法SLNB假阴性率、联合法SLNB成功率及假阴性率的差异均无统计学意义（分别P=0.731,P=0.174,P=0.947）。前瞻性研究术前淋巴显像组（82.1%显像成功）和不行淋巴显像组核素法SLNB成功率及假阴性率、联合法SLNB成功率及假阴性率的差异均无统计学意义（分别P=0.757,P=1.00,P=1.00,P=1.00）。结论 术前淋巴显像既不能提高SLNB的成功率,也不能降低其假阴性率,临床实践中乳腺癌SLNB术前可以不行淋巴显像;术中联合使用蓝染料和γ探测仪同样可以准确进行SLNB。     

乳腺癌前哨淋巴结活检

18 94年 ,美国医生Halsted首创了乳腺癌根治术 ,使术后复发率由当时的 5 8%～ 85 %下降到 6% ,开创了肿瘤器官整块广泛切除和区域淋巴结清扫的经典肿瘤外科治疗原则。 2 0世纪 70年代 ,美国学者Fisher提出乳腺癌是一种全身性疾病 ,区域淋巴结并非癌细胞滤过的有效屏障 ,血流扩散更具重要意义的理论后 ,乳腺癌手术逐步向保乳手术迅速发展。近年来 ,不少学者对乳腺癌常规行腋淋巴结清扫 (axillarylymphnodedissection ,ALND)这一金标准的必要性提出质疑 ,引发了乳腺癌外科治疗的又一次革命[1] 。近期不断有资料显示 ,较小范围的腋淋巴结切…     

Internal mammary sentinel lymph node biopsy should still be performed,especially in the patient with clinically positive axillary lymph nodes

Current studies suggest that the internal mammary sentinel lymph node biopsy (IM-SLNB) should not be performed routinely, for it did not alter clinical management of breast cancer patients in terms of adjuvant treatment. However, consideration should be given to the fact, the study population in all current research relate to IM-SLNB is the patients with clinically negative axillary lymph nodes. As internal mammary lymph nodes metastases are mostly found concomitantly with axillary metastases, clinical trials currently fail to evaluate the status of internal mammary lymph nodes who really in need. In consideration of the impact to staging and accurate indication of radiation to the internal mammary area, we recommend that research on IM-SLNB should still be encouraged, especially in patients with clinically positive axillary lymph nodes.     

Stage migration after biopsy of internal mammary chain lymph nodes in breast cancer patients

Background Involvement of the internal mammary chain lymph nodes (IMNs) is associated with worsened prognosis in breast cancer. Use of lymphoscintigraphy to visualize sentinel nodes reveals that IMNs often receive lymph from the area containing the tumor. Methods We biopsied IMNs in 182 patients because there was radiouptake to the IMNs or because the tumor was located in the medial portion of the breast. After tumor removal, pectoralis major fibers were divided to expose intercostal muscle. A portion of intercostal muscle adjacent to the sternum was removed. Lymph nodes and surrounding fatty tissue in the intercostal space were freed, removed, and analyzed histologically. The pleural cavity was breached in four cases (2.2%), with spontaneous resolution. Results IMNs were found in 160 (88%) of 182 patients; 146 (94.4%) were negative and 14 (8.8%) were positive. The latter received internal mammary chain radiotherapy. The axilla was negative in 4 of 14 cases and positive in 10. Conclusions IMNs can be quickly and easily removed via the breast incision with insignificant risk and no increase in postoperative hospitalization. The patients with a positive IMN migrated from N0 (4 cases) or N1 (10 cases) to N3, prompting modification of both local (radiotherapy to internal mammary chain) and systemic treatment; without IMN sampling, they would have been understaged.     

Internal mammary sentinel node biopsy for breast cancer

Background

The purpose of this study was to determine the value of lymphoscintigraphy (LS) for internal mammary sentinel node (IMSN) identification, the metastatic rate, and the change in staging and treatment.

Methods

Between 2001 and 2007 a prospective database was obtained of all patients undergoing IMSN biopsies using an open or thoracoscopic approach. Radiotracer injection was peritumoral.

Results

Thirty-four patients were included. There was one man. Three had ductal carcinoma in situ. LS showed IMSN in 47.1%. The IMSN biopsy success rate was 91.2%. Seven of the 28 successfully biopsied invasive cancer patients had metastatic IMSNs (25%). Positive IMSNs were associated with positive axillary nodes in 71.4% (P = .036). All patients with positive IMSNs were upstaged and received radiation to the internal mammary chain. In 4 of 28 patients (14%) the chemotherapy plans were probably altered. In univariate and multivariate analyses tumor size, location, nuclear grade, estrogen receptors, progesterone receptors, Her-2, and histology were not significant predictors of positivity.

Conclusions

IMSNs were positive in 25% of the invasive cancer patients. All had treatment changes. LS identified less than 50% of IMSNs. There are no good tumor-related predictors of IMSN positivity.     

乳腺癌前哨淋巴结检测的临床研究

目的通过前哨淋巴结(sentinel lymph node,SLN)活检,了解前哨淋巴结是否能反映乳腺癌腋窝淋巴结转移情况,从而决定是否行腋窝淋巴结清扫(axillary lymph node dissection,ALND). 方法 47例T1、T2、T3临床检查腋窝淋巴结无肿大的乳腺癌患者,术前30 min于乳腺肿块周围腺体注射蓝色染料,术中取蓝染的SLN病理检查,术后将病理检查结果与腋窝淋巴结转移情况进行比较分析. 结果 47例中5例未见淋巴结及淋巴管蓝染,其余42例找到腋窝淋巴结608个,阳性18例168个,阴性24例440个;SLN共78个,阳性16例29个,阴性26例49个.SLN的检出率89.4%,准确性95.2% ,特异性100%,敏感性88.9%,假阴性率11.1%,假阳性率0. 结论 SLN活检反应腋窝淋巴结的肿瘤转移状况,可以用于术中确定是否行ALND.     

乳腺癌前哨淋巴结活检替代腋窝清扫术前瞻性非随机对照临床研究

目的：探讨前哨淋巴结活检术（sentinel lymph node biopsy，SLNB）替代腋淋巴结切除术（axiHary lymph node dissection．ALND）的可行性。方法：联合应用亚甲蓝和^99mTc标记的硫胶体进行SLNB。2001年12月起山东省肿瘤医院乳腺病中心两个治疗组收治的临床T1.2N0M0乳腺癌病人进入本前瞻性非随机对照临床研究。A组病人SLNB后均行ALND。B组病人签署知情同意书，不同意SLNB替代ALND病人（B1组）治疗同A组；同意SLNB替代ALND病人（B2组）依据SLN状况，SLN阴性仅行SLNB，SLN阳性行ALND。结果：2001年12月-2005年6月共入组642例病人，其中A组114例（17．8％），B组528例（82.2％），B1组195例，B2组333例。B2组病人SLN阴性240例仅行SLNB；SLN阳性93例，其中87例接受ALND，另6例SLN镜下微小转移灶者中4例仅行SLNB，2例接受SLNB加区域淋巴结放疗。SLNB替代ALND者各项术后并发症显著低于ALND者（均P〈0．05）。B2组244例仅行SLNB病人中位随访26个月（7-48个月），2例病人发现区域淋巴结复发（0．82％），与ALND腋淋巴结阴性组病人（0％）相比差异无统计学意义（P〉0．05）。SLN术中冰冻快速病理诊断准确率98．5％，假阴性率5．4％。结论：SLNB可以缩小手术范围、减少病人术后并发症。SLN术中冰冻快速病理诊断具有较高的准确性，能够满足临床需要。     

Internal mammary sentinel node metastases in an otherwise lymph-node negative breast cancer patient

A 35 year old woman with biopsy proved breast cancer was submitted for sentinel node (SN) biopsy. Preoperative lymphoscintigraphy displayed both axillary and internal mammary (IM) uptake foci consistent with SNs. Full axillary dissection was completed because of a greater-than 2 cm primary lesion. Two axillary SNs were excised. An IM SN was also excised through the second intercostal space, with the aid of the gamma probe. Fourteen axillary nodes, including SNs, were negative, whereas the IM SN harbored several metastatic implants. Implications for staging, prognosis and further therapy of such IM-only positive sentinel nodes are discussed.